Pancreatic Cancer Stages

After someone is diagnosed with pancreatic cancer, doctors will try to figure out if it has spread, and if so, how far. This process is called staging. The stage of a cancer describes how much cancer is in the body. The earliest stage of pancreas cancer is stage 0 (carcinoma in situ), and then ranges from stages I (1) through IV (4). As a rule, the lower the number, the less the cancer has spread. A higher number, such as stage IV, means a more advanced cancer.

For pancreatic cancer, doctors use the cancer’s stage to discuss survival statistics. However, for discussions on how best to treat pancreatic cancer, that is based on whether the tumor can be surgically removed, also described as whether the tumor is resectable. Upon diagnosis, pancreatic cancer is described as either resectable, borderline resectable, or unresectable (see below for more information).

How is the stage determined?

The staging system used most often for pancreatic cancer is the AJCC (American Joint Committee on Cancer) TNM system, which is based on 3 key pieces of information:

• The extent of the tumor (T): How large is the tumor and has it grown outside the pancreas into nearby blood vessels?
• The spread to nearby lymph nodes (N): Has the cancer spread to nearby lymph nodes? If so, how many of the lymph nodes have cancer?
• The spread (metastasized) to distant sites (M): Has the cancer spread to distant lymph nodes or distant organs, such as the liver, peritoneum (the lining of the abdominal cavity), lungs, or bones?

The system described below is the most recent AJCC system, effective December 2023. It is used to stage most pancreatic cancers except for pancreatic neuroendocrine tumors (NETs), which have their own staging system.

The staging system in the table uses the pathologic stage. It is determined by examining tissue removed during an operation. This is also known as the surgical stage. Sometimes, if the doctor's physical exam, imaging, or other tests show the tumor is too large or has spread to nearby organs and cannot be removed by surgery right away or at all, radiation or chemotherapy might be given first. In this case, the cancer will have a clinical stage. It is based on the results of physical exam, biopsy, and imaging tests (see Tests for Pancreatic Cancer). The clinical stage can be used to help plan treatment. To learn more, see Cancer Staging.

Numbers or letters after T, N, and M provide more details about each of these factors. Higher numbers mean the cancer is more advanced. Once a person’s T, N, and M categories have been determined, this information is combined in a process called stage grouping to assign an overall stage.

Cancer staging can be complex. If you have any questions about your stage, please ask your doctor to explain it to you in a way you understand. (Additional information of the TNM system also follows the stage table below.)

Stages of pancreatic cancer

AJCC Stage	Stage grouping	Stage description*
0	Tis N0 M0	The cancer is confined to the top layers of pancreatic duct cells and has not invaded deeper tissues. It has not spread outside of the pancreas. These tumors are sometimes referred to as carcinoma in situ (Tis). This category includes the precancers, such as high-grade pancreatic intraepithelial neoplasia (PanIn-3), intraductal papillary mucinous neoplasm with high-grade dysplasia, intraductal tubulopapillary neoplasm with high-grade dysplasia, and mucinous cystic neoplasm with high-grade dysplasia. It has not spread to nearby lymph nodes (N0) or to distant sites (M0).
IA	T1 N0 M0	The cancer is confined to the pancreas and is no bigger than 2 cm across (T1). It has not spread to nearby lymph nodes (N0) or to distant sites (M0).
IB	T2 N0 M0	The cancer is confined to the pancreas and is larger than 2 cm but no more than 4cm across (T2). It has not spread to nearby lymph nodes (N0) or to distant sites (M0).
IIA	T3 N0 M0	The cancer is confined to the pancreas and is bigger than 4 cm across (T3). It has not spread to nearby lymph nodes (N0) or to distant sites (M0).
IIB	T1 N1 M0	The cancer is confined to the pancreas and is no bigger than 2 cm across (T1) AND it has spread to no more than 3 nearby lymph nodes (N1). It has not spread to distant sites (M0).
	T2 N1 M0	The cancer is confined to the pancreas and is larger than 2 cm but no more than 4 cm across (T2) AND it has spread to no more than 3 nearby lymph nodes (N1). It has not spread to distant sites (M0).
	T3 N1 M0	The cancer is confined to the pancreas and is bigger than 4 cm across (T3) AND it has spread to no more than 3 nearby lymph nodes (N1). It has not spread to distant sites (M0).
III	T1 N2 M0	The cancer is confined to the pancreas and is no bigger than 2 cm across (T1) AND it has spread to 4 or more nearby lymph nodes (N2). It has not spread to distant sites (M0).
	OR
	T2 N2 M0	The cancer is confined to the pancreas and is larger than 2 cm  but no more than 4 cm across (T2) AND it has spread to 4 or more nearby lymph nodes (N2). It has not spread to distant sites (M0).
	OR
	T3 N2 M0	The cancer is confined to the pancreas and is bigger than 4 cm across (T3) AND it has spread to 4 or more nearby lymph nodes (N2). It has not spread to distant sites (M0).
	OR
	T4 Any N M0	The cancer is growing outside the pancreas and into nearby major blood vessels (T4). The cancer may or may not have spread to nearby lymph nodes (Any N). It has not spread to distant sites (M0).
IV	Any T Any N M1	The cancer has spread to distant sites such as the liver, peritoneum (the lining of the abdominal cavity), lungs or bones (M1). It can be any size (Any T) and might or might not have spread to nearby lymph nodes (Any N).

* The following additional categories are not listed on the table above:

• TX: The main tumor cannot be assessed due to lack of information.
• T0: There is no evidence of a primary tumor.
• NX: Regional lymph nodes cannot be assessed due to lack of information.

Resectable versus unresectable pancreatic cancer

The AJCC staging system gives a detailed summary of how far the cancer has spread. But for treatment purposes, doctors use a simpler staging system, which divides cancers into groups based on whether they can be removed (resected) with surgery:

• Resectable
• Borderline resectable
• Unresectable (either locally advanced or metastatic)

Resectable

If the cancer is only in the pancreas (or has spread just beyond it) and the surgeon believes the entire tumor can be removed, it is called resectable.

It’s important to note that some cancers might appear to be resectable based on imaging tests, but once surgery is started it might become clear that not all of the cancer can be removed. If this happens, only some of the cancer may be removed to confirm the diagnosis (if a biopsy hasn’t been done already), and the rest of the planned operation will be stopped to help avoid the risk of major side effects.

Borderline resectable

This term is used to describe a pancreatic tumor that is touching and possibly surrounding a small part of nearby blood vessels. However, after initial chemo or a combination of chemo and radiation, the surgeon may still be able to remove the tumor completely. The definition of borderline resectable varies, regarding exactly which vessels and to what extent the tumor can surround those vessels. 

Unresectable

These cancers can’t be removed entirely by surgery.

Locally advanced: If the cancer has not spread to distant organs but it still can’t be removed completely with surgery, it is called locally advanced. Often the reason the cancer can’t be removed is because it has grown into or surrounded nearby major blood vessels.

Surgery to try to remove these tumors would be very unlikely to be helpful and would have major side effects. Certain procedures could still be done, but they would be less extensive with the goal of preventing or relieving symptoms like a blocked bile duct, instead of trying to remove the pancreatic tumor.

Metastatic: If the cancer has spread to distant organs, it is called metastatic (Stage IV). These cancers can’t be removed completely. Certain procedures could still be done, but the goal would be to prevent or relieve symptoms, not to try to cure the cancer.

Other prognostic factors

Although not formally part of the TNM system, other factors are also important in determining a person’s prognosis (outlook).

Tumor grade

The grade describes how closely the cancer looks like normal tissue under a microscope.

• Grade 1 (G1) means the cancer looks much like normal pancreas tissue.
• Grade 3 (G3) means the cancer looks very abnormal.
• Grade 2 (G2) falls somewhere in between.

Low-grade cancers (G1) tend to grow and spread more slowly than high-grade (G3) cancers. Most of the time, Grade 3 pancreatic cancers tend to have a poor prognosis (outlook) compared to Grade 1 or 2 cancers.

Extent of resection

For patients who have surgery, another important factor is the extent of the resection — whether or not all of the tumor is removed:

• R0: All the cancer is thought to have been removed. (There are no visible or microscopic signs suggesting that cancer was left behind.)
• R1: All visible tumor was removed, but lab tests of the removed tissue show that some small areas of cancer were probably left behind.
• R2: Some visible tumor could not be removed.

Tumor markers (CA 19-9)

Tumor markers are substances that can sometimes be found in the blood when a person has cancer. CA 19-9 is a tumor marker that is helpful in pancreatic cancer. A drop in the CA 19-9 level after surgery (compared to the level before surgery) tends to predict a better prognosis (outlook).

There are other reasons why CA19-9 may be elevated, including biliary infection or obstruction. These reasons may be due to other causes and not be cancer related. Some people with pancreatic cancer may not make CA 19-9 and would always have low levels.